Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos)

Background

Peroral cholangioscopy (POC) provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother−baby endoscope system is not widely used because of several limitations. Although direct cholangioscopy with an ultraslim upper endoscope with a guidewire has been reported, success is not always guaranteed.

Objective

To evaluate the feasibility and success rate of direct POC using an ultraslim endoscope with an intraductal balloon to maintain access compared with the guidewire method.

Design

Prospective, observational clinical feasibility study.

Setting

Tertiary referral center.

Main Outcome Measurements

We compared overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system.

Patients and Methods

Twenty-nine patients with biliary disease underwent direct POC. All patients had previously undergone an endoscopic sphincterotomy or papillary balloon dilation with a large balloon. Eleven patients underwent wire-guided direct POC. Intraductal balloon-guided direct POC was performed in 21 patients. The balloon catheter was used to maintain access while an ultraslim upper endoscope was advanced over the balloon catheter, through the ampulla of Vater, and directly into the bile duct.

Results

Wire-guided direct POC was successful in 5 of 11 (45.5%) patients. In contrast, the success rate of intraductal balloon-guided direct POC was 95.2% (20/21 patients, P < .05). Forceps biopsies under direct visualization of the intraductal lesion and therapeutic intervention, including laser lithotripsy or electrohydraulic lithotripsy, were performed successfully. Procedure-related complications were not observed.

Limitations

A small number of patients and no comparison with conventional cholangioscopy.

Conclusions

Intraductal balloon-guided direct POC with an ultraslim upper endoscope allows the direct visual examination and therapeutic intervention of bile ducts in patients with biliary disease. Further development of the endoscopic apparatus and specialized accessories are expected to facilitate this procedure.

Abbreviations: CBD, common bile duct, IHD, intrahepatic duct, POC, peroral cholangioscopy